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Clinical Conditions II > Final - Thermal Injuries > Flashcards

Final - Thermal Injuries Flashcards

1
Q

7 major functions of the skin

A
  • temperature regulation
  • protection
  • sensation
  • excretion
  • immunity
  • blood reservoir
  • Vitamin D synthesis
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2
Q

Pathophysiology of Burns

A

When someone gets burned, their skin absorbs heat. This causes tissue coagulation –> broken down into 3 zones:
coagulation, stasis, hyperemia

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2
Q

Pathophysiology of Burns

A

When someone gets burned, their skin absorbs heat. This causes tissue coagulation –> broken down into 3 zones:
coagulation, stasis, hyperemia

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3
Q

Zone of Coagulation

A
  • Occurs at the point of maximum damage

- Irreversible tissue loss due to coagulation of the constituent proteins

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4
Q

Zone of Stasis

A
  • Surrounding zone is stasis is characterized by decreased tissue perfusion
  • tissue is potentially salvageable
  • main aim of burns resuscitation is to increase tissue perfusion here and prevent any damage from becoming irreversible
  • additional insults (prolonged hypotension, infection, edema, etc) can convert this zone into an area of complete tissue loss
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5
Q

Zone of Hyperemia

A
  • outermost zone
  • perfusion is increased
  • tissue here will recover unless there is severe sepsis or prolonged hypoperfusion
  • these three zones of a burn are three dimensional, and loss of tissue in the zone of stasis will lead to the wound deepening as well as widening
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6
Q

Superficial/First Degree Burn

A

Epidermis Injured

*bad sunburn

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7
Q

Partial Thickness/Second Degree Burn

A
  • Superficial partial-thickness: superficial dermis injured

- Deep partial-thickness: deep dermis damaged with hair follicles and sweat glands intact

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8
Q

Full Thickness/ Third Degree Burn

A

Entire dermis is injured

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9
Q

Full Thickness/ Fourth Degree Burn

A

Muscle, bone injured

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10
Q

Appearance of First Degree/Superficial Burns

A
  • pink or red
  • may have edema
  • no blisters
  • blanches
  • skin/sensation intact
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11
Q

First Degree Burn Healing Time

A

3-5 days through epithelization

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12
Q

Second Degree/Superficial Partial Thickness Appearance

A
  • Pink or red
  • edema present
  • moist with blisters
  • blanches with quick refill
  • sensation intact
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13
Q

Second Degree/Superficial Partial Thickness Healing

A

1-2 weeks through epithelization

changes in pigmentation

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14
Q

Second Degree/Deep Partial Thickness Appearance

A
  • Pink or ivory
  • Dry with blisters
  • May have no light touch, decreased pinprick
  • Can feel deep pressure
  • Hair easily removed
  • Blanch with slow refill
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15
Q

Second Degree/Deep Partial Thickness Healing

A

2-3 weeks with epithelization
will likely need graft
scar formation likely

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16
Q

Third or Fourth Degree/ Full Thickness Appearance

A
  • white, red, brown, black
  • dry, may have blisters
  • no blanching
  • no sensation
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17
Q

Third or Fourth Degree/ Full Thickness Healing

A

> 3 weeks with granulation and epithelization

usually requires surgery

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18
Q

Mechanisms of Burns

A
  • Thermal
  • Electrical
  • Chemical
  • UV and Radiation
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19
Q

Most common to least common thermal burns

A

scald
flame
flash
contact

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20
Q

What does severity of thermal burns depend on?

A
  • location of burn, temperature of the source, and duration of the contact
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21
Q

Characteristic of electrical burns

A
  • entrance and exit wounds
  • muscles, tissues, nerves, and bones act as conductors
  • nerve damage common
  • arc wounds
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22
Q

Explain the varying severity of electrical burns

A
  • smaller more distal areas are damaged the most severely leading to high amputation incidence
  • severity is related to duration of contact, voltage, and the pathway, resistance, and amperage of the current through the body tissues
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23
Q

Chemical burns can be with or without what?

A

associated thermal injury

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24
Q

what does the severity of chemical burns depend on?

A
  • type of chemical
  • concentration of chemical
  • duration of contact
  • mechanism of action
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25
Q

UV and radiation burns

A
  • can be with or without thermal injury
  • most often happens after radiation treatment with cancer
  • often referred to as acute radiation syndrome
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26
Q

Rule of Nines

A
  • TBSA tells you about the change of survival
  • quick and easy to use (especially in emergencies)
  • modifications can be used if the entire body part is not burned
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27
Q

Do infants and children use the same rule of nines as adults?

A

no

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28
Q

Lund and Bower Formula

A
  • more exact and accurate than rule of nines
  • better for irregularly shaped burns
  • ABA prefers the use of this method in conjunction with palmar method where the patient’s palm is 1% of TBSA
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29
Q

No matter what measurement tool you use, what should you take into account?

A

burns are dynamic wounds which means that accurate measurement and classifications of the burn can not be made until the burn is completely developed

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30
Q

Complications of Thermal Burns

A
  • Cardiovascular: increased generalized body edema, increased HR, decreased SV and CO
  • Renal and GI issues
  • Respiratory Issues
31
Q

Complications in electrical burns

A
  • cardiovascular (EKG for all patients)
  • neurological issues
  • orthopedic
  • damage to organs, cataracts, tympanic membrane rupture, anxiety, depression, PTSD
32
Q

Those with documented LOC or arrhythmia following an electrical burn should do what?

A

be admitted for telemetry monitoring

33
Q

Complications of chemical burns

A
  • System toxicity due to subcutaneous absorption (liver toxicity, renal dysfunction)
  • Pulmonary complications (bronchospasm, edema, epithelial sloughing)
34
Q

Complications of UV and Radiation Burns

A
  • GI
  • Hematologic
  • Vascular (endothelium destruction)
35
Q

What hematologic complications are associated with UV and radiation burns?

A
  • Pancytopenia: decreased RBC, WBC, platelets
  • Granulocytopenia: decreased granular leukocytes
  • Thrombocytopenia: decreased platelets
  • Hemorrhage
36
Q

Complications of ALL burns

A
  • marked hypermetabolism
  • skeletal muscle catabolism
  • decreased pulmonary function
  • depression, stress, anxiety
  • PTSD, nightmares, insomnia
37
Q

How much is resting energy expenditure following a burn increased by?

A

20-100%

remains increased for months to years

38
Q

3 phases of wound healing

A
  • Inflammatory phase: 3-5 days
  • Proliferative phase: 2-3 weeks
  • Maturation phase: >3 weeks
39
Q

Inflammatory phase of healing

A

3-5 days

inflammation begins, fibroblasts start to travel to the wound, rid wound of foreign tissue

40
Q

proliferative phase

A

2-3 weeks
fibroblasts reach the wound, angiogenesis and granulation occur, collagen is made for the wound, wound contractures begin to form

41
Q

Resuscitative Phase

A
  • monitoring for inhalation injury and carbon monoxide poising
  • fluid resuscitation (burn shock)
  • infection control
  • body temperature and maintenance (hypothermia)
  • pain management
42
Q

initial care during resuscitative phase

A
  • address burns with wound care, topical agents, and debridement if necessary
  • escharotomy and fasciotomy
43
Q

Reparative phase

A
  • scarring: normotrophic, hypertrophic, keloid

- wounds that take more than 21 days to heal are 78% more likely to form hypertrophic and keloid scars

44
Q

what populations are keloid scars more common in?

A
  • young women

- people with darker pigmented skin

45
Q

Surgical procedures during reparative phase

A
  • eschar is dead dermis that is attached to the wound bed and prevents normal wound healing
  • excision is the removal of eschar to promote wound closure
46
Q

Why is grafting performed during the reparative phase?

A

to optimize functioning

47
Q

PT considerations for grafting

A
  • WB restrictions
  • specific protocol for that patient
  • is the graft across or close to a joint?
  • donor site is often more painful than actual burn
48
Q

Autograft

A
  • graft patients own skin from a donor site

- AROM can start POD 5

49
Q

homograft/allograft

A
  • graft cadaver skin
  • temporary to help with healing and protection from infection
  • ROM can start POD 1
50
Q

Heterograft/Zenograft

A
  • graft from pig skin
  • temporary
  • ROM can start POD 1
51
Q

Skin Substitutes - Biobrane

A
  • temporary –> 1-2 weeks
  • used on freshly debreided partial thickness wounds and donor sites
  • can be protection for an autograft
52
Q

Skin Substitutes- Integra

A
  • temporary coverage of full thickness or deep partial thickness wounds
  • will eventually be removed and replaced with thin autografts one blood supply is adequate
53
Q

Non-surgical procedures

A
  • wound debridement by PT, nurse, physician
  • priority is maintaining moist healing environment, maximizing granulation and epithelization, and minimizing tissue trauma and infection
  • benefits of electric stimulation on reducing surface area of wounds
54
Q

What occurs after wounds have healed and swelling had decreased?

A

pt might receive compression garments for keloid scarring

55
Q

Mortality with burn population

A
  • higher TBSA = higher risk of death
  • ages 75 and older
  • increased BMI
  • presence of comorbidities
  • precent of inhalation injuries
56
Q

how does gender affect mortality in burn population?

A
  • hormonal levels change your cell mediated immune response
  • increased with women between ages of 13-39 and 50-59
  • elderly women even if they have less severe injuries than male counter parts
57
Q

Infection control for burn population

A
  • scrubs
  • no lab jacket
  • gowns, masks, gloves
  • follow hand washing procedures
58
Q

patients that need to be seen in specialized setting

A
  • burn involving face, hands, feet, eyes, ears or perineum
  • electrical burn involving 110-220 volts or higher
  • 20% TBSA burn
  • 10% in child or older adult
  • > 5% full thickness burn
59
Q

Taking a history

A
  • does the story make sense?
  • does it change?
  • possible signs of abuse?
  • get patients story and families version if possible
  • get in contrast with social worker if needed
  • document everything
60
Q

Objective assessment

A
  • level of consciousness
  • pain at rest, with PROM, AAROM, and AROM
  • location of grafts, dressings, splints, garments
  • presence and location of edema
  • current positioning
  • vitals
  • MMT if possible
  • sensation
61
Q

are debridement, fasciotomy, heterografts, and synthetic dressings contraindications for exercise?

A

no!

skin grafts over joint might halt PT in a particular area for a couple of days

62
Q

Treatment during Acute Phase - ICU

A
  • position changes
  • edema control (compression sleeves or pumps using <50 mmhg)
  • pts should receive therapy 2x/day even if they are sedated
63
Q

Therex in ICU

A
  • Short duration, high frequency
  • AROM > AAROM > PROM
  • sitting endurance, standing endurance, gait
  • spending time in chair increases alertness, encourages WBing, and facilities pulmonary function
  • try to start 1.5-2 hrs out of bed
  • deep breathing exercises
64
Q

How to manage pain in acute phase

A
  • schedule therapy sessions for when medication is most effective
  • in unconscious pt’s, monitor vitals for pain
65
Q

ROM of shoulder and elbow/forearm during acute phase

A
  • shoulder : 90 degrees abduction, ER, 10 degrees horizontal adduction
  • elbow/forearm: extension with supination
66
Q

Role of PT after autograft

A
  • pre-op ROM, stretch, function
  • re-start gentle ROM day 5 (dependent on graft adherence)
  • splints may continue to be used for night/sleeping
  • progressive stretching to end range PROM as needed by day 7
67
Q

If a graft has not “take” by day 7-10,

A

it is considered graft loss

68
Q

Gait in the ICU

A
  • should be done within 48 hrs and when medically stable
  • less DVTs and PEs
  • shorter hospital stays
  • pt can ambulate immediately after graft surgery as long as compression is applied
  • be careful of gait belt placement
69
Q

Contraindications of gait in acute phase

A
  • fractures in LE
  • pre injury inability to walk
  • wounds >300 cm might have to wait 3-5 days
  • overriding psychiatric conditions
  • medical status prohibiting mobilization
  • plantar surface of foot is grafted
70
Q

mobility training during acute phase

A
  • consider hand placement and location of burn
  • ensure dressings remain intact
  • avoid shearing forces over burned area
  • compression and/or muscle pumping of dependent limbs
  • monitor vitals, especially burns >15 % TBSA
  • gait belt may or may not be appropriate
  • may need additional assistance in ICU
71
Q

Treatment in subacute inpatient phase

A
  • continue working on ROM
  • stretching with low force and long duration
  • repeated gait assessments to detect contractures at knee or hip
  • continue deep breathing for respiratory health and stress/pain control
72
Q

long term care- outpatient

A
  • pt needs to be reassessed after d/c
  • goals of rehab will change
  • full functional ROM and increasing tolerance for ambulation
  • 30 mins aerobic exercise 3-5 times per week
  • 30 mins strengthening activities 2-3 nonconsecutive days/week
  • 6-12 weeks of OP therapy indicated
  • scar massage 3x/day for 5 min
  • desensitization
  • pain control
  • discharge with HEP
73
Q

about how many patient return to their pre-burn environment?

A

95%

74
Q

Compression garments

A
  • continues to be standard
  • 30-45 mmhg
  • can flatten and improve scar by 92%
  • decreases hydration of scar, reduces neovascularization, and accelerated the remission phase of the post-burn reparative process
75
Q

how long does a pt wear compression garments?

A

2+ years, weaning into wearing it for 23 hrs a day

76
Q

silicone compression garments

A

watch for maceration and contact dermatitis

Clinical Conditions II (11 decks)

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